Abstract

INTRODUCTION: Strongyloidiasis is an intestinal nematode infection caused by Strongyloides stercoralis. The prevalence of S. stercoralis is higher in HTLV-1 positive patients. Enhanced proliferation and decreased clearance is well documented in immunocompromised hosts. This hyperinfective state is associated with invasion of the gastrointestinal and respiratory system and may result in widespread dissemination into other body organs.

CASE PRESENTATION: We present a case of a 35-year-old Jamaican with a history of HTLV-1, who initially presented with severe abdominal pain, vomiting, twenty-pound weight loss and iron deficiency anemia. Endoscopy with biopsy revealed intestinal flattening with Strongyloides parasites (Figure 1). He was treated for his intestinal strongyloidiasis with ivermectin for two days. Three years later, he presented with a two-month history of fever, cough, shortness of breath, approximately ten-pound weight loss and generalized lymphadenopathy. Lymph node biopsy revealed adult T-cell lymphoma. The chest radiograph and CT scan revealed multiple parenchymal infiltrates. Bronchosopy with bronchoalveolar lavage revealed larvae of Strongyloidoses stercolaris (Figure 2). He was given six courses of hyper-CVAD regimen for Adult T-cell Leukemia/lymphoma (ATLL), as well as a two-day course of ivermectin and a ten-day course of albendazole 400mg twice daily for Strongyloidiasis. The patient was discharged after clinical improvement. Within a month after discharge, the patient was re-admitted with a history of increasing dyspnea at rest. While on broad-spectrum antibiotics and anti-parasitic therapies, the patient developed worsening hypoxemic respiratory failure and gram negative septicemia with Vancomycin-resistant enterococcus faecium. Despite aggressive treatment he expired due to multisystem organ failure.

DISCUSSIONS: Disseminated Strongyloidiasis is a significant contributor to the morbidity and mortality in immunocompromised patients. The mortality rate has been documented up to 86%. HTLV-1 and Strongyloidiasis are well-documented co-morbidities. Patients co-infected with HTLV-1 had higher levels of interferon-gamma and interleukin (IL) -10 and lower levels of IL-4, IL-5 and IgE than patients without Strongyloidiasis without HTLV-1. This was indicative of a relative switch from Th2 to Th1 response, which is important in the control of helminthic infection. This may contribute to severity of the disease and failure to respond to standard therapy. Eosinophils are thought to play an important part in protecting the host from fulminant infection. Our patient also had a poor eosinophil response.Gram-negative sepsis is a major cause of mortality in these patients. The organism is thought to play a part in direct spread of enteral organisms during its migration. Due to the overall immunocompromised state, standard therapy with albendazole and ivermectin for hyperinfection may not have been sufficient to eradicate the organisms. Further testing of the stool or special staining of the biopsy tissue should have been performed to ensure complete eradication of the organism. In cases where worm eradication is impossible or re-infection can not be confirmed, repeat treatment with thiabendazole, albendazole or ivermectin is indicated. The treatment duration may need to be extended based on clinical resolution. Short monthly courses of antihelminthic therapy have been shown to decrease the worm load and thus, prevent recurrent systemic disease.

CONCLUSION: In summary, conventional treatment duration's for S. stercoralis, predicated on normal host immunity, may not be sufficient to eradicate the organism in immunocompromised hosts.

Return to: A CASE OF PERSISTENT STRONGYLOIDES INFECTION IN THE IMMUNOCOMPROMISED PATIENT: FAILURE OF STANDARD THERAPY

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